Surrounded by friends, community support workers, public health officials and representatives of the world’s media, Jean-François Mary came close to bursting into tears. “I’m sorry,” he said. “I just lost another friend two weeks ago. We honestly can’t wait any longer.”

Mary, executive director of the Quebec Association for the Promotion of the Health of People Who Use Drugs, was speaking at a press conference called in May 2017 to mark the opening of Montréal’s first safe injection site. Three of the sites (plus one mobile site), which allow drug users to inject themselves under the supervision of a nurse or health worker and without fear of arrest, are scheduled to open in Montréal in 2017, and expected to assist several hundred people each day.

There are currently two operational, legal safe injection sites in Canada, both in Vancouver. Community organizations in more than a dozen other cities have applied to Health Canada, with the support of their respective provincial health ministries, regional health authorities and municipal governments, to open safe injection sites.

The wave of new sites is partly a result of an initiative by federal health minister Jane Philpott, who spearheaded the passing of Bill C-37, which reduces the number of acceptability criteria needed to open a site from 26 – a list established under the Conservative government’s Respect for Communities act – to five.

“On one hand, we’re very happy to see the sites opening. On the other hand, we waited ten years for this,” says Mary. “Ten years in which we lost so many of our friends. Every time we talk about this, I see their faces. We don’t have the enthusiasm that we should have, seeing these sites open, because it took us ten years to get there!”

“People are going to use anyway, whether there are safe injection sites or not,” he says. “It’s a safety risk, but injecting in public is an even larger safety risk. People risk theft, violence, arrest and overdose. These sites will give people a chance to use with dignity and to seek support if they want it.”

Mary is an articulate, clean-cut community health worker who would not look out of place hosting a poetry slam. He is also an occasional drug user. “A lot of people react negatively to safe injection sites because of the stereotype of the drug user, of these lost souls who can’t control their consumption. But I work with a lot of people who have a full-time job, who are taxpayers and who use drugs. We don’t want to glamorize drug use, but we do want to stop stigmatizing it.”

For Sandhia Vadlamudy, executive director of Cactus, a Montreal nonprofit that provides information, clean equipment and other services to drug users, the approvals could not come fast enough. The safe injection site at Cactus, which had been approved under the Conservative criteria, took more than two years to get off the ground. “When the Harper government was in power, we could not work on harm reduction. Now, with the new government, harm reduction is part of the strategy. That also gave us time to educate people at the provincial level.” Another key factor, Vadlamudy explains, is the opioid crisis. Public health workers say opiates such as fentanyl and carfentanil, along with other poisons, are being labelled as or mixed with heroin or other more common street drugs, so users don’t know what they have until it’s too late. More than 100 people in British Columbia died of opiate overdoses in the first four months of 2017.

“Drug use happens,” says public health minister Lucie Charlebois, whose ministry freed up $12 million in provincial funding to allow the Montreal sites to operate. “It would be great if we could stick our heads in the sand and say it didn’t happen, but it does happen, so we have to act.”

“You know the facts; you know there’s bad dope around,” says Pierre Frappier, a community activist and occasional drug user from Québec City. “Everyone who says ‘not in my backyard’ should realize that it’s coming for your backyard. Fentanyl is coming, people are going to start dying and it should not take a person dead on the steps of l’église Saint-Roch for people to start ensuring people’s safety.”

No safe injection sites have yet been approved in Québec City, although the administration of Mayor Régis Labeaume has said in the past that a site inside a hospital or CLSC was a possibility.

Frappier is not the only activist who believes the clock is ticking. In January 2017, the Canada Border Services Agency announced the first seizure of a shipment of carfentanil, labelled with the name of another drug, at Montréal’s Mirabel Airport.

Carfentanil, legally used to tranquilize large animals, is 100 times stronger than fentanyl and about 5,000 times stronger than morphine. Mary says some of the opiate, which can kill at doses smaller than a grain of salt, has found its way onto Montréal’s black market, often deliberately mislabelled. “We have done tests and we know it’s already here,” Mary says. He hopes that if users are encouraged to inject in a clinical setting, health workers can administer overdose reversal drugs such as naloxone and call 911 before it’s too late. “Should we wait until the situation gets as bad as it is in Western Canada or in the U.S.? Or should we act?”

The main room of one Montréal site, located on an upper floor of a CLSC near Cactus’ downtown offices, consists of 10 spotless tables and desks, with partitions between them for privacy. Though austere, it’s worlds away from a grimy shooting gallery or an intimidating, fluorescent-lit doctor’s office. It could be a library computer lab.

Vadlamudy explains that users will be welcomed by a community health worker and a peer support worker – “so if the person just wants to talk, they can do that.”

Then the health worker will do a brief evaluation – is the person in emotional distress? Are they intoxicated? The person will give their first name, a pseudonym or their initials, and tell staff what drug they think they have. “We say ‘think’ because you never really know what’s in there, and we don’t have the equipment to do the tests ourselves. But we have to have at least an idea, because if someone overdoses on a stimulant, it’s not the same treatment as someone who has overdosed on opiates,” says Vadlamudy.

The person will take all the time they need to inject, then clean their space and move on to the recovery room, where they can spend as much or as little time as they like before going on with their day. Users can also speak with community health workers about getting into therapy or trying to get off drugs.

It’s a relatively straightforward operation, but the sites have been decades in the making. The first safe injection site in North America, Vancouver’s InSite, opened in 2003 with an approval from the federal government (known as an “exemption” because it exempts the site from Criminal Code provisions on drug possession).

The Harper government failed to renew its exemption in 2008, and InSite took the government to court. At the Supreme Court of Canada, lawyers successfully argued that closing the site violated drug users’ Charter right to personal safety. However, the ruling led to the Protecting Communities Act, which established public acceptability criteria so stringent that no site outside Vancouver was able to complete the application process – until this year.

Louis Letellier de Saint-Just, a founding board member of CACTUS, has spent more than two decades at the forefront of the battle to get the Montréal site open, and seen the evolution of public attitudes toward the project. “When we first began doing needle exchange programs here, I remember huge arguments, almost riots outside our doors. I remember only a few years ago, the former mayor saying there would never be a safe injection site at Cactus. It took many years of work with neighbourhood committees to help ease the tension.”

“We first began fighting for this in 2001,” says Mario Gagnon of the users’ rights organization Point de Repères in Québec City, Letellier’s longtime collaborator. “We lobbied for it and we marched for it. We did kind of lower our arms when the Conservatives were in power, but after the InSite case, discussions reopened. There was a time when I heard from businesspeople who were against the site, but now more and more people are open to it.”

Carole Poirier, the MNA for the downtown Montréal riding of Hochelaga-Maisonneuve, does not see social acceptability as a problem for the sites. “I have received a few concerns from parents at a high school located not far from the sites, but we’re responding to their concerns. There has been a needle exchange there for many years and very few people know it’s there; [the safe injection site] would not be any different. When we first started promoting clean needle exchanges, during the AIDS crisis, there was such a racket, a lot of pas dans ma cour. But it’s not like there’s a big flashing sign in front of it … people who need it use it, and people who don’t, don’t know it’s there.”

“In the neighbourhood, people don’t want to find needles on the street or to see [users] injecting themselves in back alleys. Having a safe injection site is safer for users and safer for the community,” Poirier says. “This shows that we live in a modern society that sees drug addiction as a public health issue. Finally, finally, finally.”

As public opinion on the sites evolves, increasing numbers of Canadian doctors are getting behind the program. The Canadian Medical Association has spoken out in favour of making the sites easier to open. “InSite has changed the conversation,” says Dr. Mark Tyndall of the British Columbia Centres for Disease Control. “InSite has shown us that the counter-arguments do not make sense. No one at the centre was using for their first time, and about 50 per cent of users have gone into treatment or substitution therapy. The new legislation [making it easier to establish the sites] is a step in the right direction, but we’ve wasted a lot of time. And you can’t get a dead drug user into treatment.”

Vadlamudy rejects the argument that making it easier for drug users to inject will encourage further drug use. “Prohibition and criminalization have been going on for decades, and they have not stopped drug use. The people who use safe injection sites are often people who have nowhere else to go hide out for fear of being rejected by society. If we want to help people who use drugs, if we want to reduce the negative impacts of drug use, we have to welcome these people,” she says.

As the Montréal sites open, Frappier and Gagnon will continue fighting for a site in Québec City, in memory of the people they’ve lost. “We’ve seen deaths from overdoses and infections that have directly resulted from people not getting care,” says Gagnon. “These people have lives and families. We’ve met the families and we’ve gone to the funerals. It’s clear to me that if we had this earlier, it could have saved several lives.”
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About Author

Ruby Pratka grew up in Baltimore, Maryland, studied in Ottawa and took the roundabout way to Quebec City via Russia, Slovenia, France, Switzerland, Belgium and East Africa. In addition to writing for LifeinQuebec.com and Life in Québec Magazine, she also contributes to other media outlets in English and French. She enjoys keeping a close eye on international affairs, listening to good music and singing in large groups.